Fever tree revisited: From malaria to autoinflammatory diseases

Over the centuries the idea of recurrent fevers has mainly been associated with malaria, but many other fevers, such as typhoid and diphtheria were cause for concern. It is only in recent times, with the more severe forms of fever from infectious origin becoming less frequent or a cause for worry that we started noticing recurrent fevers without any clear infectious cause, being described as having a pathogenesis of autoinflammatory nature. The use of molecular examinations in many cases can allow a diagnosis where the cause is monogenic. In other cases, however the pathogenesis is likely to be multifactorial and the diagnostic-therapeutic approach is strictly clinical. The old fever tree paradigm developed to describe fevers caused by malaria has been revisited here to describe today's periodic fevers from the periodic fever adenitis pharyngitis aphthae syndrome to the more rare autoinflammatory diseases. This model may allow us to place cases that are yet to be identified which are likely to be of multifactorial origin

Variability in clinical practice guidelines for sweetening agents in newborn infants undergoing painful procedures

Objective: Sweetening agents have been recommended in position statements and consensus documents for procedural pain management in neonates; however, it is not clear if this has resulted in widespread adoption in clinical practice. The objective of this study was to investigate unit-specific protocols for the use of sweetening agents. Methods: Structured telephone survey with qualified personnel in special care (level II) nurseries and neonatal intensive care (level III) units across Canada. The frequency and pattern of recommended use of sweetening agents was documented. Results: Eighty-six of 92 units (93.5%) participated. Sixty-four percent recommended sucrose and 2.3% recommended glucose for procedural pain management; 87.7% had a guideline. Sweetening agents were most commonly recommended for venipuncture/ venous cannulation (91.2% for both), lumbar puncture (87.7%), and heel lance (82.5%). Dosing guidelines ranged from 0.05mL of 24% sucrose solution to 3mL of 25% sucrose solution. Sweeteners were not recommended for infants with necrotizing enterocolitis (77.2%) or those who were nil per os (75%). Conclusions: Sweetening agents were recommended for procedural pain management in two-thirds of special care nurseries and neonatal intensive care units across Canada with extensive variability in specific dosing guidelines. Audits of pain management practices should therefore account for unit-specific practice guidelines.This study was supported by a Canadian Institutes of Health Research (CIHR) research studentship to Ms A Yiu, a CIHR New Investigator Award to Dr A Taddio, and a CIHR Canada Research Chair in Health Psychology to Dr J Katz. The funding did not include any input into the design and conduct of the study; collection, management, analysis, or interpretation of data; preparation, review, or approval of manuscript. There are no conflicts of interest

Predicting preschool pain-related anticipatory distress: the relative contribution of longitudinal and concurrent factors

Anticipatory distress prior to a painful medical procedure can lead to negative sequelae including heightened pain experiences, avoidance of future medical procedures, and potential non-compliance with preventative healthcare such as vaccinations. Few studies have examined the longitudinal and concurrent predictors of pain-related anticipatory distress. This paper consists of two companion studies to examine both the longitudinal factors from infancy, as well as concurrent factors from preschool that predict pain-related anticipatory distress at the preschool age. Study 1 examined how well preschool pain-related anticipatory distress was predicted by infant pain responding at 2, 4, 6 and 12 months of age. In Study 2, using a developmental psychopathology framework, longitudinal analyses examined the predisposing, precipitating, perpetuating, and present factors that led to the development of anticipatory distress during routine preschool vaccinations. A sample of 202 caregiverchild dyads was observed during their infant and preschool vaccinations (OUCH Cohort) and was used for both studies. In Study 1, pain responding during infancy was not found to significantly predict pain-related anticipatory distress at preschool. In Study 2, a strong explanatory model was created whereby 40% of the variance in preschool anticipatory distress was explained. Parental behaviours from infancy and preschool were the strongest predictors of child anticipatory distress at preschool. Child age positively predicted child anticipatory distress. This strongly suggests that the involvement of parents in pain management interventions during immunization is one of the most critical factors in predicting anticipatory distress to the preschool vaccination

The ABCDs of Pain Management: A Double-Blind Randomized Controlled Trial Examining the Impact of a Brief Educational Video on Infants’ and Toddlers’ Pain Scores and Parent Soothing Behavior

Objectives To test the efficacy of a brief behavioral pain management strategy (The ABCDs of Needle Pain Management), delivered via video, on infants’ and toddlers’ pain scores and on parental soothing behavior. Methods This was a double-blind, parallel trial design. Parent–child dyads (N = 128) were recruited before their child’s 6-month (infant) or 18-month (toddler) vaccination in a pediatric clinic and randomly assigned to watch a 5-min treatment video or a placebo video. The primary outcome was the Modified Behavior Pain Scale (Taddio et al., Journal of Pain and Symptom Management, 10, pp. 456–463, 1995), coded during four epochs (Pain Reactivity, Pain Regulation 1 min, Pain Regulation 2 min, and Pain Regulation 3 min) after the last vaccination needle. Secondary analyses examined parental use of distraction, rocking, and physical comforting over this same time period. Results Results demonstrated a treatment effect for toddlers (18-month-olds) for the Pain Regulation 1 (d = 0.84) and Pain Regulation 2 (d = 0.76) postvaccination scores. Secondary analyses found differences in parental rocking and physical comforting between treatment conditions and between age-groups (d’s = 0.37–0.54). Conclusions The ABCD pain management strategy delivered via video was an effective way to reduce toddler pain after vaccination and increase parental use of rocking and physical comforting. The treatment effect was not demonstrated with infants

Psychological interventions for vaccine injections in young children 0 to 3 years: Systematic review of randomized controlled trials and quasi-randomized controlled trials

Background: This systematic review evaluated the effectiveness of distraction for reducing infant distress during vaccinations in young children aged 0 to 3 years. Design/Methods: Database searches identified relevant randomized and quasi-randomized controlled trials. Three separate clinical questions related to variants of the psychological strategy of distraction (directed video; directed toy; nondirected toy) were pursued. Distress was identified as the critical outcome to assess the benefits of distraction and extracted from relevant trials. Distress was analyzed by phase of procedure (distress preprocedure; distress acute; distress recovery; idiosyncratic phases based on some or all of the 3 aforementioned phases). Results: Ten studies were included in the review. Significant results are presented herein. For directed video distraction, moderate quality evidence suggested that distress was lowered in the treatment group standardized mean difference (SMD -0.68 lower [95% confidence interval (CI), -1.04 to -0.32]) for the acute+recovery phase as well as the preprocedure phase (SMD -0.49 lower [95% CI, -7.6 to -0.22]). For directed toy distraction, the analysis of low-quality evidence for a combined preprocedure+acute+ recovery phase of distress (analysis n=81), suggested that distress was lowered in the treatment group (SMD -0.47 lower [95% CI, -0.91 to -0.02]). An effect for nondirected toy distraction was also seen, analyzing very-low-quality evidence, for the acute distress phase (n=290; SMD -0.93 lower [95% CI, -1.86 to 0.00]). Conclusion: Generally low-quality to very-low-quality evidence suggests that there may be an effect of directed (toy and video) and nondirected toy distraction for children aged 0 to 3 years, for certain phases of the vaccination

Student feedback to tailor the card™ system for improving the immunization experience at school

Increasing the comfort of vaccine delivery at school is needed to improve the immunization experience for students. We created the CARD™ (C—Comfort, A—Ask, R—Relax and D—Distract) system to address this clinical care gap. Originally designed for grade 7 students, this study examined the perceptions of grade 9 students of CARD™. Grade 9 students who had experience with school-based immunizations, either as recipients or onlookers (n = 7; 100% females 14 years old) participated. Students answered pre–post surveys, reviewed CARD™ educational materials and participated in a semi-structured focus group discussion. The Consolidated Framework for Implementation Research (CFIR) was used as the framework for analysis of qualitative data. Participants reported positive perceptions of CARD™ educational materials and that CARD™ could fit into the school immunization process. CARD™ improved knowledge about effective coping interventions and was recommended for education of both nurses and students. The results provide preliminary evidence that CARD™ is acceptable and appropriate for implementation in grade 9 school-based immunizations

Elevated creatine kinase is mainly harmless in children but persistent and severe hyperCKaemia should raise suspicions of serious muscle damage

N/

Pharmacological and combined interventions to reduce vaccine injection pain in children and adults systematic review and meta-analysis

Background: This systematic review assessed the effectiveness and safety of pharmacotherapy and combined interventions for reducing vaccine injection pain in individuals across the lifespan. Design/Methods: Electronic databases were searched for relevant randomized and quasi-randomized controlled trials. Self-reported pain and fear as well as observer-rated distress were critically important outcomes. Data were combined using standardized mean difference (SMD) or relative risk with 95% confidence intervals (CI). Results: Fifty-five studies that examined breastfeeding (which combines sweet-tasting solution, holding, and sucking), topical anesthetics, sweet-tasting solutions (sucrose, glucose), vapocoolants, oral analgesics, and combination of 2 versus 1 intervention were included. The following results report findings of analyses of critical outcomes with the largest number of participants. Compared with control, acute distress was lower for infants breastfed: (1) during vaccination (n=792): SMD -1.78 (CI, -2.35, -1.22) and (2) before vaccination (n=100): SMD -1.43 (CI, -2.14, -0.72). Compared with control/placebo, topical anesthetics showed benefit on acute distress in children (n=1424): SMD -0.91 (CI, -1.36, -0.47) and self-reported pain in adults (n=60): SMD -0.85 (CI, -1.38, -0.32). Acute and recovery distress was lower for children who received sucrose (n=2071): SMD -0.76 (CI, -1.19, -0.34) or glucose (n=818): SMD -0.69 (CI, -1.03, -0.35) compared with placebo/no treatment. Vapocoolants reduced acute pain in adults [(n=185), SMD -0.78 (CI, -1.08, -0.48)] but not children. Evidence from other needle procedures showed no benefit of acetaminophen or ibuprofen. The administration of topical anesthetics before and breastfeeding during vaccine injections showed mixed results when compared with topical anesthetics alone. There were no additive benefits of combining glucose and non-nutritive sucking (pacifier) compared with glucose or non-nutritive sucking (pacifier) alone or breastfeeding and sucrose compared with breastfeeding or sucrose alone. Conclusions: Breastfeeding, topical anesthetics, sweet-tasting solutions, and combination of topical anesthetics and breastfeeding demonstrated evidence of benefit for reducing vaccine injection pain in infants and children. In adults, limited data demonstrate some benefit of topical anesthetics and vapocoolants